Young Leaders SEEDS™ (KL)

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● AGE: 11 - 16
● PROGRAM DATE: 2019 December 2 - 6 (9am - 5pm) *
GRADUATION DINNER: 2019 December 6 (6.30pm-9.30pm) **
● VENUE: Sri Emas International School
Lot 1214, Seksyen 40, Batu 10, Lebuhraya Persekutuan,
Off Jalan SS7/2, 47300 Petaling Jaya, Selangor, Malaysia

* Snack and Lunch are provided
** Please note that there will be an additional cost for each parent/guardian.
We will communicate with you pertaining to this.

Youth SEEDS Leadership™ is a program designed by RAIN & Origin of Wisdom™ Sdn. Bhd.

Email *

Getting them ready for 2020

Congratulations on having registered in Youth SEEDS Leadership™, created by Origin of Wisdom and Dr Annie Lim International Inc. Youth SEEDS Leadership™ is designed as an opportunity for young people to be more powerful, fully self-expressed and effective in dealing with life.

• PARTICIPANT AND PARENTS: Each one of you will have sections of this form to complete. The information requested in this form is intended to enable the participant to get the maximum results out of the Youth SEEDS Leadership™ and beyond. The information will be held in strictest confidence. All questions must be answered in full before your child can participate in Youth SEEDS Leadership™.

• Fill every space completely. When a question is not applicable, write N/A rather than leave it blank.

Participant Information (Youth)

First Name *

Last Name *

Name I Like To Be Called (On Name Tag) *

Home Address (Street/P.O. Box) *

City, State/Province *

Zip/Postal Code *

Country *

Home Phone *

Age *

Date of Birth *

YYYY

Please list the (i)name (ii)age (iii)relationship of all siblings, relatives or friends who are registered in this course (if any)

Name, Age, Relationship

Please list the (i)name (ii)age (iii)relationship of all siblings, relatives or friends who are NOT registered in this course (if any)

Name, Age, Relationship

INFORMATION OF PARENT / GUARDIAN #1

Name & Relationship *

First Name, Last Name and Relationship (Mother/Father/Legal Guardian)

Home Address (Street/P.O. Box) *

City, Province/State *

Zip/Postal Code *

Country *

We require all phone numbers in the event of an emergency. For numbers you want us to use only in the event of an emergency please type 'Emergency Only' next to that number *

Home Phone, Work Phone, Cell or Other Phone

Email address *

Have you completed SEEDS Leadership™ ?

If Yes, Kindly state City and When (Year/Month)

Marital Status

Spouse/Partner's name (if any)

Have Your Spouse/Partner completed SEEDS Leadership™ ?

If yes, Kindly state City and When (Year/Month)

INFORMATION OF PARENT / GUARDIAN #2

(leave blank if similar to the above)

Name & Relationship

First Name, Last Name and Relationship (Mother/Father/Legal Guardian)

Address (Street/P.O. Box)

City, Province/State

Zip/Postal Code

Country

We require all phone numbers in the event of an emergency. For numbers you want us to use only in the event of an emergency please type 'Emergency Only' next to that number

Home Phone, Work Phone, Cell or Other Phone

Email Address

Have you completed SEEDS Leadership™ ?

If Yes, Kindly state City and When (Year/Month)

Marital Status

Spouse/Partner's Name (if any)

Have Your Spouse/Partner completed SEEDS Leadership™?

If yes, Kindly state City and When (Year/Month)

THIS SECTION IS TO BE COMPLETED BY THE PARENTS/LEGAL GUARDIANS ONLY.

What physical conditions does your child have that we should know about?

Special Condition (Physically Challenged, Wheelchair, Hearing or Vision impaired, or any other condition?). If Yes, Please specify.

IMPORTANT NOTE

We provide only one menu: If the participant has a special diet or has special food requirements of any nature, they will need to provide their own lunch. We are not able to provide refrigeration or preparation of any kind. The vending machine will not be available during Young Leaders SEEDS™ Program.

Should your child need to take any medication during the course, they will need to administer the medication themselves, or their parent/legal guardian will need to come to the course to administer the medication.

In your own words, clearly state the specific issues, concerns, complaints, and/or upsets your child is dealing with in his/her life currently.

Please indicate who is the person responding: (Mother/Father/Step-parent/Legal Guardian)

How have the above impacted your child in being fully self-expressed, and effective in his/her everyday life?

Please indicate who is the person responding: (Mother/Father/Step-parent/Legal Guardian)

THIS SECTION IS TO BE COMPLETED BY THE PARTICIPANT ONLY (Youth).

Young Leaders SEEDS™ Program is about having a life you love, being authentic and powerful and creating possibilities in your life.

To get the most out of being in the course, we ask that you say what you would like to accomplish in your life that is important to you. There may be problems or concerns that you are struggling with, and you may include those as well.

You might consider some of the following:
• What do you want to accomplish
• What do you want to make a difference with
• What is important and what matters to you
• Relationships with the people in your life:
Family/parents/brothers/sisters/friends/classmates/teachers
• School/schoolwork/chores/jobs/work

What I intend to accomplish in Youth SEEDS Leadership™ program is

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